Healthcare Provider Details

I. General information

NPI: 1346302817
Provider Name (Legal Business Name): SHANE MATTHEW BJORNBERG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11049 N 147TH EAST AVE
OWASSO OK
74055-6263
US

IV. Provider business mailing address

11049 N 147TH EAST AVE
OWASSO OK
74055-6263
US

V. Phone/Fax

Practice location:
  • Phone: 918-978-6274
  • Fax:
Mailing address:
  • Phone: 918-978-6274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3967
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT 3550
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: